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Acun C, Ali M, Liu W, Karnati S, Fink K, Aly H. Effectiveness and Safety of Dexmedetomidine in Neonates With Hypoxic Ischemic Encephalopathy Undergoing Therapeutic Hypothermia. J Pediatr Pharmacol Ther 2024; 29:232-240. [PMID: 38863848 PMCID: PMC11163906 DOI: 10.5863/1551-6776-29.3.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/15/2023] [Indexed: 06/13/2024]
Abstract
OBJECTIVE The objective of this study was to evaluate and compare the effectiveness and safety of dexmedetomidine as monotherapy between neonates with mild hypoxic ischemic encephalopathy (HIE) and moderate to severe HIE treated with therapeutic hypothermia (TH). METHODS This retrospective study included neonates of gestational age ≥36 weeks with a diagnosis of HIE and undergoing TH between January 2014 and December 2021. Patients were included if they received at least 6 hours of continuous sedation with dexmedetomidine. Baseline characteristics, dose and duration of medication, adverse events, liver and kidney function tests, and hospital course were reviewed. RESULTS Of the 97 neonates included, 46 had mild, 42 had moderate, and 9 had severe HIE. Dexmedetomidine was initiated at a median 5 hours of life, and the median infusion duration was 77 (46-87) hours. Fifty-two (53.6%) required at least 1 breakthrough opioid or sedative during the first 24 hours of dexmedetomidine infusion. Overall, 40 patients (41.2%) had at least 1 bradycardia episode with heart rate <80 beats/min and 14 patients (14.4%) had heart rate <70 beats/min. Hypotension was experienced by 7 patients (7.2%). Fifty-two patients (53.6%) were intubated in the delivery room and 33/52 (63.5%) were extubated on day of life 1 during dexmedetomidine infusion. CONCLUSIONS Dexmedetomidine as monotherapy was effective and safe sedation for infants with HIE undergoing hypothermia. The most common side effect of dexmedetomidine was bradycardia. -Dexmedetomidine may be considered as first and single agent for neonates with HIE undergoing TH.
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Affiliation(s)
- Ceyda Acun
- Department of Neonatology, Cleveland Clinic Children’s Hospital, Department of Pediatrics, (CA, SK, KF, HA), Metro Health-Cleveland (MA), Departments of Quantitative Health Sciences and Radiology, Cleveland Clinic, (WL) Cleveland, OH
| | - Mahmoud Ali
- Department of Neonatology, Cleveland Clinic Children’s Hospital, Department of Pediatrics, (CA, SK, KF, HA), Metro Health-Cleveland (MA), Departments of Quantitative Health Sciences and Radiology, Cleveland Clinic, (WL) Cleveland, OH
| | - Wei Liu
- Department of Neonatology, Cleveland Clinic Children’s Hospital, Department of Pediatrics, (CA, SK, KF, HA), Metro Health-Cleveland (MA), Departments of Quantitative Health Sciences and Radiology, Cleveland Clinic, (WL) Cleveland, OH
| | - Sreenivas Karnati
- Department of Neonatology, Cleveland Clinic Children’s Hospital, Department of Pediatrics, (CA, SK, KF, HA), Metro Health-Cleveland (MA), Departments of Quantitative Health Sciences and Radiology, Cleveland Clinic, (WL) Cleveland, OH
| | - Kelsey Fink
- Department of Neonatology, Cleveland Clinic Children’s Hospital, Department of Pediatrics, (CA, SK, KF, HA), Metro Health-Cleveland (MA), Departments of Quantitative Health Sciences and Radiology, Cleveland Clinic, (WL) Cleveland, OH
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children’s Hospital, Department of Pediatrics, (CA, SK, KF, HA), Metro Health-Cleveland (MA), Departments of Quantitative Health Sciences and Radiology, Cleveland Clinic, (WL) Cleveland, OH
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Gundersen JK, Chakkarapani E, Menassa DA, Walløe L, Thoresen M. The effects of anaesthesia on cell death in a porcine model of neonatal hypoxic-ischaemic brain injury. BJA OPEN 2024; 10:100283. [PMID: 38741692 PMCID: PMC11089311 DOI: 10.1016/j.bjao.2024.100283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 03/30/2024] [Indexed: 05/16/2024]
Abstract
Background Hypothermia is neuroprotective after neonatal hypoxic-ischaemic brain injury. However, systemic cooling to hypothermic temperatures is a stressor and may reduce neuroprotection in awake pigs. We compared two experiments of global hypoxic-ischaemic injury in newborn pigs, in which one group received propofol-remifentanil and the other remained awake during post-insult hypothermia treatment. Methods In both studies, newborn pigs were anaesthetised using halothane during a 45-min global hypoxic-ischaemic insult induced by reducing Fio2 and graded hypotension until a low-voltage <7 μV electroencephalogram was achieved. On reoxygenation, the pigs were randomly allocated to receive 24 h of normothermia or hypothermia. In the first study (n=18) anaesthesia was discontinued and the pigs' tracheas were extubated. In the second study (n=14) anaesthesia was continued using propofol and remifentanil. Brain injury was assessed after 72 h by classical global histopathology, Purkinje cell count, and apoptotic cell counts in the hippocampus and cerebellum. Results Global injury was nearly 10-fold greater in the awake group compared with the anaesthetised group (P=0.021). Hypothermia was neuroprotective in the anaesthetised pigs but not the awake pigs. In the hippocampus, the density of cleaved caspase-3-positive cells was increased in awake compared with anaesthetised pigs in normothermia. In the cerebellum, Purkinje cell density was reduced in the awake pigs irrespective of treatment, and the number of cleaved caspase-3-positive Purkinje cells was greatly increased in hypothermic awake pigs. We detected no difference in cleaved caspase-3 in the granular cell layer or microglial reactivity across the groups. Conclusions Our study provides novel insights into the significance of anaesthesia/sedation during hypothermia for achieving optimal neuroprotection.
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Affiliation(s)
- Julia K. Gundersen
- Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Ela Chakkarapani
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, UK
| | - David A. Menassa
- Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Department of Neuropathology and The Queen's College, University of Oxford, Oxford, UK
- Department of Women's & Children's Health, Karolinska Institutet, Solna, Sweden
| | - Lars Walløe
- Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Marianne Thoresen
- Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, UK
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Liu CH, Liu HY, Peng SC, Pan S, Wan ZT, Wu SY, Fang CC, Jiao R, Wang WX, Gan B, Shu-JieYang, Tan JF, Zhu XF, She PL, Fan QH, Yang M, Xie JJ, Sun J, Zeng L, Zhang LH, Xu HR, Li YN, Zhang PF, Lu W, Yang XT, Xiao XF, Li HL, Rao ZL, Gao C, Luo YH, Chen H, Yu MJ, Luan XY, Huang YR, Xia SW. Effect of birth asphyxia on neonatal blood glucose during the early postnatal life: A multi-center study in Hubei Province, China. Pediatr Neonatol 2023; 64:562-569. [PMID: 37105821 DOI: 10.1016/j.pedneo.2021.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/13/2021] [Accepted: 11/29/2021] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Birth asphyxia causes hypoxia or inadequate perfusion to the organs of newborns, leading to metabolism dysfunctions including blood glucose disorders. METHODS Neonates with and without birth asphyxia were retrospectively recruited from 53 hospitals in Hubei Province from January 1 to December 31, 2018. In summary, 875, 1139, and 180 cases in the control group, the mild asphyxia group, and the severe asphyxia group were recruited, respectively. Neonatal blood glucose values at postnatal 1, 2, 6, and 12 h (time error within 0.5 h was allowed) were gathered from the medical records. RESULTS The incidence rates of hyperglycemia in the control group, the mild asphyxia group and the severe asphyxia group were 2.97%, 7.90%, and 23.33%, respectively (p < 0.001). Additionally, the incidence rates of hypoglycemia in the three groups above were 3.66%, 4.13%, and 7.78%, respectively (p = 0.042). The blood glucose values of neonates with hypoglycemia in the asphyxia group were lower than in the control group (p = 0.003). Furthermore, the blood glucose values of neonates with hyperglycemia were highest in the severe asphyxia group (p < 0.001). There were 778 and 117 cases with blood glucose records at four predefined time points in the mild and severe asphyxia group, respectively. The incidence of blood glucose disorders in the mild asphyxia group significantly decreased from postnatal 6 h (p<0.05). However, we found no obvious changes of the incidence of glucose disorders within postnatal 12 h in the severe asphyxia group (p = 0.589). CONCLUSION Birth asphyxia is likely to cause neonatal blood glucose disorders, both hypoglycemia and hyperglycemia, during the early postnatal life. The neonates with severe asphyxia have higher incidence, worse severity and longer duration of blood glucose disorders than neonates with mild asphyxia.
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Affiliation(s)
- Chun-Hua Liu
- Department of Neonatology, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Department of Neonatology, Xianning Central Hospital, First Affiliated Hospital of Hubei University of Science and Technology, Xianning, China; School of Medicine, Wuhan University of Science and Technology, Wuhan, China
| | - Hong-Yan Liu
- Department of Neonatology, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Si-Cong Peng
- Department of Neonatology, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sha Pan
- Department of Neonatology, Xianning Central Hospital, First Affiliated Hospital of Hubei University of Science and Technology, Xianning, China
| | - Zhi-Ting Wan
- Department of Neonatology, Xianning Central Hospital, First Affiliated Hospital of Hubei University of Science and Technology, Xianning, China
| | - Su-Ying Wu
- Department of Neonatology, University Hospital of Hubei Minzu University, Enshi, China
| | - Chao-Ce Fang
- Department of Neonatology, University Hospital of Hubei Minzu University, Enshi, China
| | - Rong Jiao
- Department of Pediatrics, Xiangyang NO.1 People's Hospital, Xiangyang, China
| | - Wen-Xiang Wang
- Department of Pediatrics, Xiangyang NO.1 People's Hospital, Xiangyang, China
| | - Bin Gan
- Department of Neonatology, The Central Hospital of Xiaogan, Xiaogan, China
| | - Shu-JieYang
- Department of Neonatology, The Central Hospital of Xiaogan, Xiaogan, China
| | - Ju-Fang Tan
- Department of Neonatology, Jingzhou Central Hospital, Jingzhou, China
| | - Xiao-Fang Zhu
- Department of Neonatology, Jingzhou Central Hospital, Jingzhou, China
| | - Ping-Li She
- Department of Neonatology, The First People's Hospital of Jingzhou, Jingzhou, China
| | - Qi-Hong Fan
- Department of Neonatology, The First People's Hospital of Jingzhou, Jingzhou, China
| | - Min Yang
- Department of Pediatrics, Children's Medical Center, Affiliated Taihe Hospital of Hubei University of Medicine, Shiyan, China
| | - Ji-Jian Xie
- Department of Pediatrics, Children's Medical Center, Affiliated Taihe Hospital of Hubei University of Medicine, Shiyan, China
| | - Jie Sun
- Department of Neonatology, Huanggang Central Hospital, Huanggang, China
| | - Ling Zeng
- Department of Neonatology, Huanggang Central Hospital, Huanggang, China
| | - Lian-Hong Zhang
- Department of Neonatology, The First People's Hospital of Tianmen, Tianmen, China
| | - Hui-Rong Xu
- Department of Neonatology, The First People's Hospital of Tianmen, Tianmen, China
| | - Yan-Ni Li
- Department of Pediatrics, Xiangyang Maternal and Child Health Care Hospital, Xiangyang, China
| | - Ping-Feng Zhang
- Department of Pediatrics, Xiangyang Maternal and Child Health Care Hospital, Xiangyang, China
| | - Wei Lu
- Department of Pediatrics, Yichang Central People's Hospital, Yichang, China
| | - Xian-Tao Yang
- Department of Pediatrics, Yichang Central People's Hospital, Yichang, China
| | - Xiong-Fei Xiao
- Department of Neonatology, Tianmen Maternal and Child Health Care Hospital, Tianmen, China
| | - Hong-Li Li
- Department of Pediatrics, Hanchuan Maternal and Child Health and Family Planning Service Center, Hanchuan, China
| | - Zheng-Liang Rao
- Department of Pediatrics, Yingshan People's Hospital, Yingshan, China
| | - Chuang Gao
- Department of Pediatrics, Yingshan People's Hospital, Yingshan, China
| | - Ya-Hui Luo
- Department of Neonatology, Hanchuan People's Hospital, Hanchuan, China
| | - Hong Chen
- Department of Neonatology, Qichun People's Hospital, Qichun, China
| | - Ming-Jin Yu
- Department of Neonatology, Qichun People's Hospital, Qichun, China
| | - Xiao-Ying Luan
- Department of Pediatrics, Yunmeng Hospital of Traditional Chinese Medicine, Yunmeng, China
| | - Yu-Rong Huang
- Department of Pediatrics, Gong An County People's Hospital, Gong'an, China
| | - Shi-Wen Xia
- Department of Neonatology, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Lugli L, Garetti E, Goffredo BM, Candia F, Crestani S, Spada C, Guidotti I, Bedetti L, Miselli F, Della Casa EM, Roversi MF, Simeoli R, Cairoli S, Merazzi D, Lago P, Iughetti L, Berardi A. Continuous Fentanyl Infusion in Newborns with Hypoxic-Ischemic Encephalopathy Treated with Therapeutic Hypothermia: Background, Aims, and Study Protocol for Time-Concentration Profiles. Biomedicines 2023; 11:2395. [PMID: 37760835 PMCID: PMC10525845 DOI: 10.3390/biomedicines11092395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
Therapeutic hypothermia (TH) is the standard of care for newborns with moderate to severe hypoxic-ischemic encephalopathy (HIE). Discomfort and pain during treatment are common and may affect the therapeutic efficacy of TH. Opioid sedation and analgesia (SA) are generally used in clinical practice, and fentanyl is one of the most frequently administered drugs. However, although fentanyl's pharmacokinetics (PKs) may be altered by hypothermic treatment, the PK behavior of this opioid drug in cooled newborns with HIE has been poorly investigated. The aim of this phase 1 study protocol (Trial ID: FentanylTH; EUDRACT number: 2020-000836-23) is to evaluate the fentanyl time-concentration profiles of full-term newborns with HIE who have been treated with TH. Newborns undergoing TH receive a standard fentanyl regimen (2 mcg/Kg of fentanyl as a loading dose, followed by a continuous infusion-1 mcg/kg/h-during the 72 h of TH and subsequent rewarming). Fentanyl plasma concentrations before bolus administration, at the end of the loading dose, and 24-48-72-96 h after infusion are measured. The median, maximum, and minimum plasma concentrations, together with drug clearance, are determined. This study will explore the fentanyl time-concentration profiles of cooled, full-term newborns with HIE, thereby helping to optimize the fentanyl SA dosing regimen during TH.
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Affiliation(s)
- Licia Lugli
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Elisabetta Garetti
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Bianca Maria Goffredo
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, Scientific Institute for hospitalization and care (IRCCS), 00100 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Francesco Candia
- Pediatrics Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (F.C.); (S.C.); (L.I.)
| | - Sara Crestani
- Pediatrics Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (F.C.); (S.C.); (L.I.)
| | - Caterina Spada
- Neonatal Unit, Women’s and Children’s Department, Bufalini Hospital of Cesena, 47521 Cesena, Italy;
| | - Isotta Guidotti
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Luca Bedetti
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Francesca Miselli
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41100 Modena, Italy;
| | - Elisa Muttini Della Casa
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Maria Federica Roversi
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Raffaele Simeoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, Scientific Institute for hospitalization and care (IRCCS), 00100 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Sara Cairoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, Scientific Institute for hospitalization and care (IRCCS), 00100 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Daniele Merazzi
- Neonatal Unit, Women’s and Children’s Department, Valduce Hospital, 22100 Como, Italy;
| | - Paola Lago
- Neonatal Intensive Care Unit, Women’s and Children’s Department, Ca’ Foncello Hospital, 31100 Treviso, Italy;
| | - Lorenzo Iughetti
- Pediatrics Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (F.C.); (S.C.); (L.I.)
| | - Alberto Berardi
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
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Kamino D, Widjaja E, Brant R, Ly LG, Mamak E, Chau V, Moore AM, Williams T, Tam EW. Severity and duration of dysglycemia and brain injury among patients with neonatal encephalopathy. EClinicalMedicine 2023; 58:101914. [PMID: 37181414 PMCID: PMC10166778 DOI: 10.1016/j.eclinm.2023.101914] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 03/02/2023] [Accepted: 03/02/2023] [Indexed: 05/16/2023] Open
Abstract
Background Evidence is needed to inform thresholds for glycemic management in neonatal encephalopathy (NE). We investigated how severity and duration of dysglycemia relate to brain injury after NE. Methods A prospective cohort of 108 neonates ≥36 weeks gestational age with NE were enrolled between August 2014 and November 2019 at the Hospital for Sick Children, in Toronto, Canada. Participants underwent continuous glucose monitoring for 72 h, MRI at day 4 of life, and follow-up at 18 months. Receiver operating characteristic curves were used to assess the predictive value of glucose measures (minimum and maximum glucose, sequential 1 mmol/L glucose thresholds) during the first 72 h of life (HOL) for each brain injury pattern (basal ganglia, watershed, focal infarct, posterior-predominant). Linear and logistic regression analyses were used to assess the relationship between abnormal glycemia and 18-month outcomes (Bayley-III composite scores, Child Behavior Checklist [CBCL] T-scores, neuromotor score, cerebral palsy [CP], death), adjusting for brain injury severity. Findings Of 108 neonates enrolled, 102 (94%) had an MRI. Maximum glucose during the first 48 HOL best predicted basal ganglia (AUC = 0.811) and watershed (AUC = 0.858) injury. Minimum glucose was not predictive of brain injury (AUC <0.509). Ninety-one (89%) infants underwent follow-up assessments at 19.0 ± 1.7 months. A glucose threshold of >10.1 mmol/L during the first 48 HOL was associated with 5.8-point higher CBCL Internalizing Composite T-score (P = 0.029), 0.3-point worse neuromotor score (P = 0.035), 8.6-fold higher odds for CP diagnosis (P = 0.014). While the glucose threshold of >10.1 mmol/L during the first 48 HOL was associated with higher odds of the composite outcome of severe disability or death (OR 3.0, 95% CI 1.0-8.4, P = 0.042), it was not associated with the composite outcome of moderate-to-severe disability or death (OR 0.9, 95% CI 0.4-2.2, P = 0.801). All associations with outcome lost significance after adjusting for brain injury severity. Interpretation Maximum glucose concentration in the first 48 HOL is predictive of brain injury after NE. Further trials are needed to assess if protocols to control maximum glucose concentrations improve outcomes after NE. Funding Canadian Institutes for Health Research, National Institutes of Health, and SickKids Foundation.
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Affiliation(s)
- Daphne Kamino
- Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, M5G 0A4, Canada
| | - Elysa Widjaja
- Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, M5G 0A4, Canada
- Department of Diagnostic Imaging, The Hospital for Sick Children and University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - Rollin Brant
- BC Children's Hospital Research Institute, Vancouver, BC, V5Z 4H4, Canada
- Department of Statistics, The University of British Columbia, Vancouver, BC, V6T 1Z4, Canada
| | - Linh G. Ly
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - Eva Mamak
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Vann Chau
- Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, M5G 0A4, Canada
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - Aideen M. Moore
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - Tricia Williams
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Emily W.Y. Tam
- Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, M5G 0A4, Canada
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, M5G 1X8, Canada
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Nakhleh-Philippe P, Zores C, Stern-Delfils A, Escande B, Astruc D, Severac F, Kuhn P. Adequacy of sedation analgesia to support the comfort of neonates undergoing therapeutic hypothermia and its impact on short-term neonatal outcomes. Front Pediatr 2023; 11:1057724. [PMID: 36969279 PMCID: PMC10034099 DOI: 10.3389/fped.2023.1057724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/13/2023] [Indexed: 03/29/2023] Open
Abstract
Objectives We aimed to evaluate (1) whether sedation analgesia (SA) used during therapeutic hypothermia (TH) was efficient to support the wellbeing of neonates with hypoxic-ischemic encephalopathy, (2) the SA level and its adjustment to clinical pain scores, and (3) the impact of inadequate SA on short-term neonatal outcomes evaluated at discharge. Methods This was an observational retrospective study performed between 2011 and 2018 in two level III centers in Alsace, France. We analyzed the wellbeing of infants by using the COMFORT-Behavior (COMFORT-B) clinical score and SA level during TH, according to which we classified infants into four groups: those with excess SA, adequate SA, lack of SA, and variability of SA. We analyzed the variations in doses of SA and their justification. We also determined the impact of inadequate SA on neonatal outcomes at discharge by multivariate analyses with multinomial regression, with adequate SA as the reference. Results A total of 110 patients were included, 89 from Strasbourg university hospital and 21 from Mulhouse hospital. The COMFORT-B score was assessed 95.5% of the time. Lack of SA was mainly found on the first day of TH (15/110, 14%). In all, 62 of 110 (57%) infants were in excess of SA over the entire duration of TH. Most dose variations were related to clinical pain scores. Inadequate SA was associated with negative short-term consequences. Infants with excess of SA had a longer duration of mechanical ventilation [mean ratio 1.46, 95% confidence interval (CI), 1.13-1.89, p = 0.005] and higher incidence of abnormal neurological examination at discharge (odds ratio 2.61, 95% CI, 1.10-6.18, p = 0.029) than infants with adequate SA. Discussion Adequate SA was not easy to achieve during TH. Close and regular monitoring of SA level may help achieve adequate SA. Excess of SA can be harmful for newborns with hypoxic-ischemic encephalopathy who are undergoing TH.
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Affiliation(s)
- Pauline Nakhleh-Philippe
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
- Department of Neonatology, Hospital of Mulhouse, Mulhouse, France
| | - Claire Zores
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
- Strasbourg University, Institut des Neurosciences Cellulaires et Intégratives, Strasbourg, France
| | | | - Benoît Escande
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
| | - Dominique Astruc
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
| | - François Severac
- Department of Public Health and Epidemiology, University Hospital of Strasbourg, Strasbourg, France
| | - Pierre Kuhn
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
- Strasbourg University, Institut des Neurosciences Cellulaires et Intégratives, Strasbourg, France
- Neonatal Research Unit, Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Correspondence: Kuhn Pierre
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Therapeutic Interventions in Rat Models of Preterm Hypoxic Ischemic Injury: Effects of Hypothermia, Caffeine, and the Influence of Sex. Life (Basel) 2022; 12:life12101514. [PMID: 36294948 PMCID: PMC9605553 DOI: 10.3390/life12101514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/21/2022] [Accepted: 09/23/2022] [Indexed: 11/30/2022] Open
Abstract
Infants born prematurely have an increased risk of experiencing brain injury, specifically injury caused by Hypoxia Ischemia (HI). There is no approved treatment for preterm infants, in contrast to term infants that experience Hypoxic Ischemic Encephalopathy (HIE) and can be treated with hypothermia. Given this increased risk and lack of approved treatment, it is imperative to explore and model potential treatments in animal models of preterm injury. Hypothermia is one potential treatment, though cooling to current clinical standards has been found to be detrimental for preterm infants. However, mild hypothermia may prove useful. Caffeine is another treatment that is already used in preterm infants to treat apnea of prematurity, and has shown neuroprotective effects. Both of these treatments show sex differences in behavioral outcomes and neuroprotective effects, which are critical to explore when working to translate from animal to human. The effects and research history of hypothermia, caffeine and how sex affects these treatment outcomes will be explored further in this review article.
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Abstract
Chronic pain and agitation in neonatal life impact the developing brain. Oral sweet-tasting solutions should be used judiciously to mitigate behavioral responses to mild painful procedures, keeping in mind that the long-term impact is unknown. Rapidly acting opioids should be used as part of premedication cocktails for nonemergent endotracheal intubations. Continuous low-dose morphine or dexmedetomidine may be considered for preterm or term neonates exhibiting signs of stress during mechanical ventilation and therapeutic hypothermia, respectively. Further research is required regarding the pharmacokinetics, pharmacodynamics, safety, and efficacy of pharmacologic agents used to mitigate mild, moderate, and chronic pain and stress in neonates.
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Affiliation(s)
- Christopher McPherson
- Department of Pharmacy, St. Louis Children's Hospital, 1 Children's Place, St. Louis, MO 63110, USA; Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
| | - Ruth E Grunau
- Department of Pediatrics, University of British Columbia, F605B, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver BC V5Z 4H4, Canada
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Kamash P, Ding Y. Hypothermia promotes synaptic plasticity and protective effects in neurological diseases. Brain Circ 2021; 7:294-297. [PMID: 35071849 PMCID: PMC8757500 DOI: 10.4103/bc.bc_28_21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/13/2021] [Accepted: 08/07/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Peter Kamash
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
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Lugli L, Spada C, Garetti E, Guidotti I, Roversi MF, Della Casa E, Bedetti L, Lucaccioni L, Pugliese M, Ferrari F, Iughetti L, Lago P, Berardi A. Fentanyl analgesia in asphyxiated newborns treated with therapeutic hypothermia. J Matern Fetal Neonatal Med 2021; 35:7764-7770. [PMID: 34486466 DOI: 10.1080/14767058.2021.1937106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Therapeutic hypothermia is the standard care for asphyxiated newborns. Discomfort and pain during treatment are common and may affect therapeutic efficacy of hypothermia. Opioid analgosedation is commonly used in the clinical setting, but its effects in the cooled newborns is poorly investigated. OBJECTIVE The aim of this study was to assess the safety of fentanyl analgosedation during therapeutic hypothermia, by evaluating severe adverse effects and possible correlation with the neurodevelopmental outcome. METHODS We analyzed asphyxiated newborns treated with hypothermia receiving fentanyl intravenous infusion (years 2013-2018). Severe neurodevelopmental outcome was defined as cerebral palsy or Griffith's developmental quotient <70 or major sensorineural deficit. Severe brain lesions were defined as cortical or/and basal ganglia extensive involvement. RESULTS Fentanyl cumulative dose was variable (61.7 ± 18.5 µg/kg; range 34.3-120.3 µg/kg) among 45 enrolled patients. Respiratory depression was recorded in 13.3% cases of 30 spontaneously breathing patients. Severe brain lesions and severe neurodevelopmental disability were found in 24.4 and 11.1% of all included cases, respectively. Higher cumulative fentanyl dose was not associated with poor outcome. CONCLUSIONS Fentanyl treatment during therapeutic hypothermia does not negatively affect the neurodevelopmental outcome, thus on the contrary, it may contribute to ameliorate neuroprotection in the asphyxiated cooled newborns.
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Affiliation(s)
- Licia Lugli
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Caterina Spada
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Elisabetta Garetti
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Isotta Guidotti
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Maria Federica Roversi
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Elisa Della Casa
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Luca Bedetti
- Pediatrics, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
| | - Laura Lucaccioni
- Pediatrics, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
| | - Marisa Pugliese
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Fabrizio Ferrari
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Lorenzo Iughetti
- Pediatrics, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
| | - Paola Lago
- Women's and Children's Department, Neonatal Intensive Care Unit, Ca' Foncello Hospital, Treviso, Italy
| | - Alberto Berardi
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
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McPherson C, Frymoyer A, Ortinau CM, Miller SP, Groenendaal F. Management of comfort and sedation in neonates with neonatal encephalopathy treated with therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101264. [PMID: 34215538 PMCID: PMC8900710 DOI: 10.1016/j.siny.2021.101264] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Ensuring comfort for neonates undergoing therapeutic hypothermia (TH) after neonatal encephalopathy (NE) exemplifies a vital facet of neonatal neurocritical care. Physiologic markers of stress are frequently present in these neonates. Non-pharmacologic comfort measures form the foundation of care, benefitting both the neonate and parents. Pharmacological sedatives may also be indicated, yet have the potential to both mitigate and intensify the neurotoxicity of a hypoxic-ischemic insult. Morphine represents current standard of care with a history of utilization and extensive pharmacokinetic data to guide safe and effective dosing. Dexmedetomidine, as an alternative to morphine, has several appealing characteristics, including neuroprotective effects in animal models; robust pharmacokinetic studies in neonates with NE treated with TH are required to ensure a safe and effective standard dosing approach. Future studies in neonates treated with TH must address comfort, adverse events, and long-term outcomes in the context of specific sedation practices.
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Affiliation(s)
- Christopher McPherson
- Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Ave., St. Louis, MO, 63110, USA.
| | - Adam Frymoyer
- Department of Pediatrics, Stanford University, 750 Welch Road, Suite 315, Palo Alto, CA, 94304, USA.
| | - Cynthia M. Ortinau
- Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Ave., St. Louis, MO, 63110, USA
| | - Steven P. Miller
- Department of Pediatrics, The Hospital for Sick Children and the University of Toronto, 555 University Avenue, Toronto, ON, Canada
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Lundlaan 6, 3584 EA, Utrecht, Netherlands.
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12
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Practical approaches to sedation and analgesia in the newborn. J Perinatol 2021; 41:383-395. [PMID: 33250515 PMCID: PMC7700106 DOI: 10.1038/s41372-020-00878-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/06/2020] [Accepted: 11/12/2020] [Indexed: 11/08/2022]
Abstract
The prevention, assessment, and treatment of neonatal pain and agitation continues to challenge clinicians and researchers. Substantial progress has been made in the past three decades, but numerous outstanding questions remain. In this setting, clinicians must establish safe and compassionate standardized practices that consider available efficacy data, long-term outcomes, and research gaps. Novel approaches with limited data must be carefully considered against historic standards of care with robust data suggesting limited benefit and clear adverse effects. This review summarizes available evidence while suggesting practical clinical approaches to pain assessment and avoidance, procedural analgesia, postoperative analgesia, sedation during mechanical ventilation and therapeutic hypothermia, and the issues of tolerance and withdrawal. Further research in all areas represents an urgent priority for optimal neonatal care. In the meantime, synthesis of available data offers clinicians challenging choices as they balance benefit and risk in vulnerable critically ill neonates.
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Effects of temperature on plasma corticosterone in a native lizard. Sci Rep 2020; 10:16315. [PMID: 33004871 PMCID: PMC7530705 DOI: 10.1038/s41598-020-73354-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 09/15/2020] [Indexed: 12/30/2022] Open
Abstract
The glucocorticoid stress response is frequently used to indicate vertebrate response to the environment. Body temperature may affect glucocorticoid concentrations, particularly in ectotherms. We conducted lab manipulations and field measurements to test the effects of body temperature on plasma corticosterone (predominant glucocorticoid in reptiles) in eastern fence lizards (Sceloporus undulatus). First, we acclimated lizards to one of 4 treatments: 22 °C, 29 °C, 33 °C, or 36 °C, and measured cloacal temperatures and plasma corticosterone concentrations at baseline and after exposure to a standardized stressor (cloth bag). Both baseline and stress-induced corticosterone concentrations were lower in lizards with lower body temperatures. Second, we acclimated lizards to 22 °C or 29 °C and exposed them to a standardized (cloth bag) stressor for 3 to 41 min. Lizards acclimated to 29 °C showed a robust increase in plasma corticosterone concentrations with restraint stress, but those at 22 °C showed no such increases in corticosterone concentrations. Third, we measured lizards upon capture from the field. There was no correlation between body temperature and baseline plasma corticosterone in field-caught lizards. These results suggest body temperature can significantly affect plasma corticosterone concentrations in reptiles, which may be of particular concern for experiments conducted under laboratory conditions but may not translate to the field.
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McPherson C, O'Mara K. Provision of Sedation and Treatment of Seizures During Neonatal Therapeutic Hypothermia. Neonatal Netw 2020; 39:227-235. [PMID: 32675319 DOI: 10.1891/0730-0832.39.4.227] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2020] [Indexed: 06/11/2023]
Abstract
Hypoxic-ischemic encephalopathy (HIE) produces a high rate of long-term neurodevelopmental disability in survivors. Therapeutic hypothermia dramatically improves the incidence of intact survival, but does not eliminate adverse outcomes. The ideal provision of sedation and treatment of seizures during therapeutic hypothermia represent therapeutic targets requiring optimization in practice. Physiologic stress from therapeutic hypothermia may obviate some of the benefits of this therapy. Morphine is commonly utilized to provide comfort, despite limited empiric evidence supporting safety and efficacy. Dexmedetomidine represents an interesting alternative, with preclinical data suggesting direct efficacy against shivering during induced hypothermia and neuroprotection in the setting of HIE. Pharmacokinetic properties must be considered when utilizing either agent, with safety dependent on conservative dosing and careful monitoring. HIE is the leading cause of neonatal seizures. Traditional therapies, including phenobarbital, fosphenytoin, and benzodiazepines, control seizures in the vast majority of neonates. Concerns about the acute and long-term effects of these agents have led to the exploration of alternative anticonvulsants, including levetiracetam. Unfortunately, levetiracetam is inferior to phenobarbital as first-line therapy for neonatal seizures. Considering both the benefits and risks of traditional anticonvulsant agents, treatment should be limited to the shortest duration indicated, with maintenance therapy reserved for neonates at high risk for recurrent seizures.
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Wassink G, Davidson JO, Fraser M, Yuill CA, Bennet L, Gunn AJ. Non-additive effects of adjunct erythropoietin therapy with therapeutic hypothermia after global cerebral ischaemia in near-term fetal sheep. J Physiol 2020; 598:999-1015. [PMID: 31912503 DOI: 10.1113/jp279131] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 01/02/2020] [Indexed: 01/26/2023] Open
Abstract
KEY POINTS Recombinant human erythropoietin (rEpo) is neuroprotective in immature animals, but it is unclear whether the combination of high-dose rEpo therapy with therapeutic hypothermia can further improve outcomes. Hypothermia and rEpo independently improved neuronal survival, with greater improvement with hypothermia, and similarly reduced numbers of caspase-3 positive cells and reactive microglia after 7 days recovery. Hypothermia, but not rEpo, was associated with markedly improved EEG power, whereas both interventions improved recovery of EEG frequency. There was no significant improvement in any outcome after combined rEpo and hypothermia compared with hypothermia alone, and of concern, the combination was associated with increased numbers of cortical caspase-3-positive cells compared with ischaemia-hypothermia. These data suggest that the mechanisms of neuroprotection with hypothermia and rEpo overlap and, thus, high-dose rEpo infusion does not appear to be an effective adjunct therapy for therapeutic hypothermia. ABSTRACT Therapeutic hypothermia for hypoxic-ischaemic encephalopathy (HIE) provides incomplete neuroprotection. Recombinant human erythropoietin (rEpo) is neuroprotective in immature animals, but it is unclear whether adjunct rEpo therapy with therapeutic hypothermia can further improve outcomes. Near-term fetal sheep received sham-ischaemia (n = 9) or global cerebral ischaemia for 30 min (ischaemia-vehicle, n = 8), followed by intravenous infusion of rEpo (ischaemia-Epo, n = 8; 5000 U/kg loading dose, then 833.3 U/kg/h), cerebral hypothermia (ischaemia-hypothermia, n = 8), or rEpo plus hypothermia (ischaemia-Epo-hypothermia, n = 8), from 3 to 72 h post ischaemia. Fetal brains were collected 7 days after cerebral ischaemia. Cerebral ischaemia was associated with severe neuronal loss and microglial induction in the parasagittal cortex and subcortical regions. Hypothermia reduced overall neuronal loss, cortical caspase-3 and reactive microglia in the striatum and cortex, with greater recovery of electroencephalographic (EEG) power and spectral edge (SEF) from 48 h onwards. rEpo independently improved neuronal survival in the parasagittal cortex, hippocampal CA4 and thalamus, and reduced cortical caspase-3 and activated microglia in striatal and cortical areas, with greater SEF from 120 h onwards. However, ischaemia-Epo-hypothermia did not further improve outcomes compared with ischaemia-hypothermia and was associated with increased numbers of cortical caspase-3-positive cells. These findings suggest that although delayed, prolonged treatment with both hypothermia and rEpo are independently neuroprotective, they have overlapping anti-inflammatory and anti-apoptotic mechanisms, such that the delayed, high-dose rEpo infusion for 3 days did not materially augment neuroprotection with therapeutic hypothermia.
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Affiliation(s)
- Guido Wassink
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, New Zealand
| | - Joanne O Davidson
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, New Zealand
| | - Mhoyra Fraser
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, New Zealand
| | - Caroline A Yuill
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, New Zealand
| | - Laura Bennet
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, New Zealand
| | - Alistair J Gunn
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, New Zealand
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Tylan C, Camacho K, French S, Graham SP, Herr MW, Jones J, McCormick GL, O'Brien MA, Tennessen JB, Thawley CJ, Webb A, Langkilde T. Obtaining plasma to measure baseline corticosterone concentrations in reptiles: How quick is quick enough? Gen Comp Endocrinol 2020; 287:113324. [PMID: 31733208 DOI: 10.1016/j.ygcen.2019.113324] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 11/06/2019] [Accepted: 11/12/2019] [Indexed: 12/15/2022]
Abstract
There is growing interest in the use of glucocorticoid (GC) hormones to understand how wild animals respond to environmental challenges. Blood is the best medium for obtaining information about recent GC levels; however, obtaining blood requires restraint and can therefore be stressful and affect GC levels. There is a delay in GCs entering blood, and it is assumed that blood obtained within 3 min of first disturbing an animal reflects a baseline level of GCs, based largely on studies of birds and mammals. Here we present data on the timing of changes in the principle reptile GC, corticosterone (CORT), in four reptile species for which blood was taken within a range of times 11 min or less after first disturbance. Changes in CORT were observed in cottonmouths (Agkistrodon piscivorus; 4 min after first disturbance), rattlesnakes (Crotalus oreganus; 2 min 30 s), and rock iguanas (Cyclura cychlura; 2 min 44 s), but fence lizards (Sceloporus undulatus) did not exhibit a change within their 10-min sampling period. In both snake species, samples taken up to 3-7 min after CORT began to increase still had lower CORT concentrations than after exposure to a standard restraint stressor. The "3-min rule" appears broadly applicable as a guide for avoiding increases in plasma CORT due to handling and sampling in reptiles, but the time period in which to obtain true baseline CORT may need to be shorter in some species (rattlesnakes, rock iguanas), and may be unnecessarily limiting for others (cottonmouths, fence lizards).
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Affiliation(s)
- Catherine Tylan
- Department of Biology, The Pennsylvania State University, University Park, PA 16802, USA
| | - Kiara Camacho
- Department of Biology, The Pennsylvania State University, University Park, PA 16802, USA
| | - Susannah French
- Department of Biology and the Ecology Center, Utah State University, Logan, UT 84322, USA
| | - Sean P Graham
- Department of Biology, The Pennsylvania State University, University Park, PA 16802, USA
| | - Mark W Herr
- Department of Biology, The Pennsylvania State University, University Park, PA 16802, USA
| | - Jermayne Jones
- Department of Biology, The Pennsylvania State University, University Park, PA 16802, USA
| | - Gail L McCormick
- Department of Biology, The Pennsylvania State University, University Park, PA 16802, USA; Intercollege Graduate Degree Program in Ecology, and The Center for Brain, Behavior and Cognition, The Pennsylvania State University, University Park, PA 16802, USA
| | - Melissa A O'Brien
- Department of Biology, The Pennsylvania State University, University Park, PA 16802, USA
| | - Jennifer B Tennessen
- Department of Biology, The Pennsylvania State University, University Park, PA 16802, USA; Intercollege Graduate Degree Program in Ecology, and The Center for Brain, Behavior and Cognition, The Pennsylvania State University, University Park, PA 16802, USA
| | - Christopher J Thawley
- Department of Biology, The Pennsylvania State University, University Park, PA 16802, USA; Intercollege Graduate Degree Program in Ecology, and The Center for Brain, Behavior and Cognition, The Pennsylvania State University, University Park, PA 16802, USA
| | - Alison Webb
- Department of Biology and the Ecology Center, Utah State University, Logan, UT 84322, USA
| | - Tracy Langkilde
- Department of Biology, The Pennsylvania State University, University Park, PA 16802, USA; Intercollege Graduate Degree Program in Ecology, and The Center for Brain, Behavior and Cognition, The Pennsylvania State University, University Park, PA 16802, USA.
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Üner IL, Johansen T, Dahle J, Persson M, Stiris T, Andresen JH. Therapeutic hypothermia and N-PASS; results from implementation in a level 3 NICU. Early Hum Dev 2019; 137:104828. [PMID: 31357084 DOI: 10.1016/j.earlhumdev.2019.104828] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/22/2019] [Accepted: 07/23/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Neonates that have been subjected to perinatal asphyxia and fulfill criteria for therapeutic hypothermia are cooled to 33.5 °C for 72 h. There is no consensus regarding sedation and analgesic use during hypothermia, but there is evidence supporting the importance of pain relief and adequate sedation. There is a need for assessment of the neonates need for pain relief and sedation, and for adjustments of medication to ensure adequate treatment. There are many different scoring tools available. We found the N-PASS (Neonatal Pain, Agitation and Sedation Scale) scoring tool to be the most suitable for this patient group as it assesses both pain and sedation. METHODS We translated the scoring tool according to guidelines published by Wilder et al., and scored neonates treated with therapeutic hypothermia. Sedation and analgesia were adjusted according to scoring results. At the end of the study a questionnaire was filled out by the nurses in charge of this group of patients. RESULTS Both pain and sedation scores did not reach the desired levels until day 3. The nurses reported a high level of satisfaction (79.7% were extremely of very satisfied), and 96.7% of the nurses found the neonates to be better pain relieved after the initiation of the study. CONCLUSION The implementation of the N-PASS scoring tool in our unit has been successful, and has led to better pain relief and sedation than before the implementation.
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Affiliation(s)
| | - Tove Johansen
- Department of Neonatology, Oslo University Hospital, Norway.
| | - Julie Dahle
- Department of Neonatology, Oslo University Hospital, Norway.
| | - Mette Persson
- Department of Neonatology, Oslo University Hospital, Norway.
| | - Tom Stiris
- Department of Neonatology, Oslo University Hospital, Norway; Faculty of Medicine, University of Oslo, Norway.
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Pinchefsky EF, Hahn CD, Kamino D, Chau V, Brant R, Moore AM, Tam EWY. Hyperglycemia and Glucose Variability Are Associated with Worse Brain Function and Seizures in Neonatal Encephalopathy: A Prospective Cohort Study. J Pediatr 2019; 209:23-32. [PMID: 30982528 DOI: 10.1016/j.jpeds.2019.02.027] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/17/2019] [Accepted: 02/15/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To investigate how glucose abnormalities correlate with brain function on amplitude-integrated electroencephalography (aEEG) in infants with neonatal encephalopathy. STUDY DESIGN Neonates born at full term with encephalopathy were enrolled within 6 hours of birth in a prospective cohort study at a pediatric academic referral hospital. Continuous interstitial glucose monitors and aEEG were placed soon after birth and continued for 3 days. Episodes of hypoglycemia (≤50 mg/dL; ≤2.8 mmol/L) and hyperglycemia (>144 mg/dL; >8.0 mmol/L) were identified. aEEG was classified in 6-hour epochs for 3 domains (background, sleep-wake cycling, electrographic seizures). Generalized estimating equations assessed the relationship of hypo- or hyperglycemia with aEEG findings, adjusting for clinical markers of hypoxia-ischemia (Apgar scores, umbilical artery pH, and base deficit). RESULTS Forty-five infants (gestational age 39.5 ± 1.4 weeks) were included (24 males). During aEEG monitoring, 16 episodes of hypoglycemia were detected (9 infants, median duration 77.5, maximum 220 minutes) and 18 episodes of hyperglycemia (13 infants, median duration 237.5, maximum 3125 minutes). Epochs of hypoglycemia were not associated with aEEG changes. Compared with epochs of normoglycemia, epochs of hyperglycemia were associated with worse aEEG background scores (B 1.120, 95% CI 0.501-1.738, P < .001), less sleep-wake cycling (B 0.587, 95% CI 0.417-0.757, P < .001) and more electrographic seizures (B 0.433, 95% CI 0.185-0.681, P = .001), after adjusting for hypoxia-ischemia severity. CONCLUSIONS In neonates with encephalopathy, epochs of hyperglycemia were temporally associated with worse global brain function and seizures, even after we adjusted for hypoxia-ischemia severity. Whether hyperglycemia causes neuronal injury or is simply a marker of severe brain injury requires further study.
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Affiliation(s)
- Elana F Pinchefsky
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada; Program in Neurosciences and Mental Health, SickKids Research Institute, Toronto, Ontario, Canada.
| | - Cecil D Hahn
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada; Program in Neurosciences and Mental Health, SickKids Research Institute, Toronto, Ontario, Canada
| | - Daphne Kamino
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada; Program in Neurosciences and Mental Health, SickKids Research Institute, Toronto, Ontario, Canada
| | - Vann Chau
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada; Program in Neurosciences and Mental Health, SickKids Research Institute, Toronto, Ontario, Canada; BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Rollin Brant
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada; Department of Statistics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Aideen M Moore
- Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Emily W Y Tam
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada; Program in Neurosciences and Mental Health, SickKids Research Institute, Toronto, Ontario, Canada
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19
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Lemyre B, Chau V. L’hypothermie pour les nouveau-nés atteints d’encéphalopathie hypoxo-ischémique. Paediatr Child Health 2018. [DOI: 10.1093/pch/pxy051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Brigitte Lemyre
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
| | - Vann Chau
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
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20
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Lemyre B, Chau V. Hypothermia for newborns with hypoxic-ischemic encephalopathy. Paediatr Child Health 2018; 23:285-291. [PMID: 30657134 DOI: 10.1093/pch/pxy028] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Therapeutic hypothermia is a standard of care for infants ≥36 weeks gestational age (GA) with moderate-to-severe hypoxic-ischemic encephalopathy. Because some studies included infants born at 35 weeks GA, hypothermia should be considered if they meet other criteria. Cooling for infants <35 weeks GA is not recommended. Passive cooling should be started promptly in community centres, in consultation with a tertiary care centre neonatologist, while closely monitoring the infant's temperature. Best evidence suggests that maintaining core body temperature between 33°C and 34°C for 72 hours, followed by a period of rewarming of 6 to 12 hours, is optimal. Antiepileptic medications should be used when clinical or electrographic seizures are present. Maintaining serum electrolytes and glucose within normal ranges, and avoiding hypo- or hypercarbia and hyperoxia, are important adjunct treatments. A brain magnetic resonance image (MRI) is advised shortly after rewarming and, in cases where earlier findings do not match the clinical picture, a repeat MRI after 10 days of life is suggested. Multidisciplinary neurodevelopmental follow-up is recommended.
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Affiliation(s)
- Brigitte Lemyre
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
| | - Vann Chau
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
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Kovacs K, Szakmar E, Meder U, Cseko A, Szabo AJ, Szabo M, Jermendy A. Serum cortisol levels in asphyxiated infants with hypotension. Early Hum Dev 2018; 120:40-45. [PMID: 29626704 DOI: 10.1016/j.earlhumdev.2018.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/11/2018] [Accepted: 03/13/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Kata Kovacs
- 1st Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Eniko Szakmar
- 1st Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Unoke Meder
- 1st Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Anna Cseko
- 1st Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Attila J Szabo
- 1st Department of Paediatrics, Semmelweis University, Budapest, Hungary; MTA-SE Pediatric and Nephrology Research Group, Budapest, Hungary
| | - Miklos Szabo
- 1st Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Agnes Jermendy
- 1st Department of Paediatrics, Semmelweis University, Budapest, Hungary.
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Garabedian C, Aubry E, Sharma D, Bleu G, Clermont-Hama Y, Ghesquière L, Hubert T, Deruelle P, Storme L, De Jonckheere J, Houfflin-Debarge V. Exploring fetal response to acidosis in ewes: Choosing an adequate experimental model. J Gynecol Obstet Hum Reprod 2018; 47:397-403. [PMID: 29654942 DOI: 10.1016/j.jogoh.2018.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 04/10/2018] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Knowledge of fetal physiology during labor has been largely generated from animal models. Our team recently developed a new index to assess parasympathetic activity using different experimental protocols to obtain acidosis. The objective of the present study was to discuss the different protocols and to review other models proposed in the literature. MATERIAL AND METHODS Pregnant ewes underwent a surgical procedure at the 123±2 days gestational age (term=145 days). Three experimental protocols were used: protocol A consisted of 25%, 50% and 75% umbilical cord occlusion (UCO) for 20min. Protocol B consisted of partial 75% UCO until reaching a pH<7.10. Protocol C consisted of brief, repetitive complete occlusion until severe acidosis occurred. Hemodynamic and blood gas parameters were compared to those of the stability period before UCO. RESULTS Protocol A led to a progressive response depending on the degree of occlusion (decrease in fetal heart rate, arterial hypertension and pH). Protocol B led to severe acidosis, although the duration of UCO varied per animal. Protocol C also progressively led to acidosis. We observed high inter individual variability in the acidosis response. CONCLUSION Pregnant ewes are a relevant model for exploring fetal response to acidosis. The frequency of UCO and partial or complete occlusion should be adapted to the expected effects. Knowledge of these protocols is important to respect ethical guidelines and to reduce the required number of animals. Moreover, it is important to consider the high individual variability of the acidosis response in the interpretation of the results.
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Affiliation(s)
- C Garabedian
- University Lille, EA 4489 - Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Obstetrics, F-59000 Lille, France.
| | - E Aubry
- University Lille, EA 4489 - Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Pediatric Surgery, F-59000 Lille, France
| | - D Sharma
- University Lille, EA 4489 - Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Pediatric Surgery, F-59000 Lille, France
| | - G Bleu
- University Lille, EA 4489 - Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Obstetrics, F-59000 Lille, France
| | - Y Clermont-Hama
- University Lille, EA 4489 - Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Obstetrics, F-59000 Lille, France
| | - L Ghesquière
- University Lille, EA 4489 - Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Obstetrics, F-59000 Lille, France
| | - T Hubert
- University Lille, CHU Lille, Experimental Resources Platform, F-59000 Lille, France
| | - P Deruelle
- University Lille, EA 4489 - Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Obstetrics, F-59000 Lille, France
| | - L Storme
- University Lille, EA 4489 - Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Neonatology, F-59000 Lille, France
| | - J De Jonckheere
- University Lille, EA 4489 - Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, CIC-IT 1403, MRRC, F-59000 Lille, France
| | - V Houfflin-Debarge
- University Lille, EA 4489 - Perinatal Environment and Health, F-59000 Lille, France; CHU Lille, Department of Obstetrics, F-59000 Lille, France
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Basu SK, Kaiser JR, Guffey D, Minard CG, Guillet R, Gunn AJ. Hypoglycaemia and hyperglycaemia are associated with unfavourable outcome in infants with hypoxic ischaemic encephalopathy: a post hoc analysis of the CoolCap Study. Arch Dis Child Fetal Neonatal Ed 2016; 101:F149-55. [PMID: 26283669 DOI: 10.1136/archdischild-2015-308733] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Accepted: 07/29/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the association of neonatal hypoglycaemia and hyperglycaemia with outcomes in infants with hypoxic ischaemic encephalopathy (HIE). DESIGN Post hoc analysis of the CoolCap Study. SETTING 25 perinatal centres in the UK, the USA and New Zealand during 1999-2002. PATIENTS 234 infants at ≥36 weeks' gestation with moderate-to-severe HIE enrolled in the CoolCap Study. 214 (91%) infants had documented plasma glucose and follow-up outcome data. INTERVENTION Infants were randomised to head cooling for 72 h starting within 6 h of birth, or standard care. Plasma glucose levels were measured at predetermined time intervals after randomisation. MAIN OUTCOME MEASURE The unfavourable primary outcome of the study was death and/or severe neurodevelopmental disability at 18 months. Hypoglycaemia (≤40 mg/dL, ≤2.2 mmol/L) and hyperglycaemia (>150 mg/dL, >8.3 mmol/L) during the first 12 h after randomisation were investigated for univariable and multivariable associations with unfavourable primary outcome. RESULTS 121 (57%) infants had abnormal plasma glucose values within 12 h of randomisation. Unfavourable outcome was observed in 126 (60%) infants and was more common among subjects with hypoglycaemia (81%, p=0.004), hyperglycaemia (67%, p=0.01) and any glucose derangement within the first 12 h (67%, p=0.002) compared with normoglycaemic infants (48%) in univariable analysis. These associations remained significant after adjusting for birth weight, Apgar score, pH, Sarnat stage and hypothermia therapy. CONCLUSIONS Both hypoglycaemia and hyperglycaemia in infants with moderate-to-severe HIE were independently associated with unfavourable outcome. Future studies are needed to investigate the prognostic significance of these associations and their role as biomarkers of brain injury. TRIAL REGISTRATION NUMBER (ClinicalTrials.gov NCT00383305).
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Affiliation(s)
- Sudeepta K Basu
- Baylor College of Medicine, Houston, Texas, USA Children's National Medical Center, Washington, DC, USA
| | | | - Danielle Guffey
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas, USA
| | - Charles G Minard
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas, USA
| | - Ronnie Guillet
- University of Rochester Medical Center, Rochester, Texas, New York, USA
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Wassink G, Lear CA, Gunn KC, Dean JM, Bennet L, Gunn AJ. Analgesics, sedatives, anticonvulsant drugs, and the cooled brain. Semin Fetal Neonatal Med 2015; 20:109-14. [PMID: 25457080 DOI: 10.1016/j.siny.2014.10.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Multiple randomized controlled trials have shown that prolonged, moderate cerebral hypothermia initiated within a few hours after severe hypoxia-ischemia and continued until resolution of the acute phase of delayed cell death reduces mortality and improves neurodevelopmental outcome in term infants. The challenge is now to find ways to further improve outcomes. In the present review, we critically examine the evidence that conventional analgesic, sedative, or anticonvulsant agents might improve outcomes, in relation to the known window of opportunity for effective protection with hypothermia. This review strongly indicates that there is insufficient evidence to recommend routine use of these agents during therapeutic hypothermia. Further systematic research into the effects of pain and stress on the injured brain, and their treatment during hypothermia, is essential to guide the rational development of clinical treatment protocols.
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Affiliation(s)
- Guido Wassink
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | | | - Katherine C Gunn
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Justin M Dean
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Department of Physiology, University of Auckland, Auckland, New Zealand.
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Weaver-Mikaere L, Gibbons HM, De Silva D, Fraser M. Primary mixed glial cultures from fetal ovine forebrain are a valid model of inflammation-mediated white matter injury. Dev Neurosci 2012; 34:30-42. [PMID: 22627272 DOI: 10.1159/000338039] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Astrocytes, microglial cells and oligodendrocytes (OLs) have been employed separately in vitro to assess cellular pathways following a variety of stimuli. Mixed glial cell cultures, however, have not been utilized to the same extent, despite the observed discrepancy in outcomes resulting from cell-to-cell contact of different glia in culture. Our objective was to standardize and morphologically characterize a primary culture of preterm ovine glial cells in order to attain a relevant in vitro model to assess the intracellular effects of infection and inflammation. This would provide a high-throughput model necessary for in-depth studies on the various pathophysiological mechanisms of white matter injury (WMI), which may occur in the preterm infant as a consequence of maternal infection or the fetal inflammatory response. Glial cells from the forebrains of 0.65-gestation ovine fetuses (comparable to 24- to 26-week human fetal brain development) were mechanically and enzymatically isolated and plated at a final density of 250,000 cells per well. When reaching confluence at 5 days after plating, the cultures contained astrocytes, microglial cells, as well as progenitor, precursor and immature OLs. Glial cell morphology and phenotypic immunoreactivity were characteristic of and consistent with previous observations of separately cultured cell types. To determine the effects of infection or inflammation in our in vitro model, we then treated mixed glial cultures with tumour necrosis factor-α (TNF-α; 50 or 100 ng/ml) or lipopolysaccharide (LPS; 1 µg/ml) for a period of 48 h. Cytokine levels were measured by ELISA and cell numbers for specific glial cell types were determined along with OL proliferation and apoptosis by Ki67 and caspase-3 immunocytochemistry, respectively. Our results showed that exposure to TNF-α or LPS resulted in a characteristic inflammatory response entailed by up-regulation of pro-inflammatory cytokines, a lack of astrogliosis and a marked reduction in OLs attributable to increased apoptosis. In LPS-treated cultures, there was a marked increase in the pro-inflammatory cytokine TNF-α at both 24 and 48 h. In conclusion, this is the first report of the immunocytochemical description and characterization of fetal ovine-derived mixed glial cell primary cultures. This in vitro model provides a novel and efficient system to explore the mechanisms of infection/inflammation-mediated WMI at the cellular level and for screening candidate therapeutic strategies.
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Affiliation(s)
- Luke Weaver-Mikaere
- The Liggins Institute, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Abstract
The hypothalamic-pituitary-adrenal (HPA) axis is essential for maintaining homeostasis in the fetus and newborn. A proportion of extremely preterm infants suffer from transient adrenocortical insufficiency of prematurity. Although these infants have suboptimal adrenocortical response to stress in the first week of life, the HPA axis adapts rapidly, and most exhibit an adequate response by day 14. An attenuated cortisol response in preterm infants might be protective against intracranial bleeding. Severe hypoxic-ischemic encephalopathy is a potent stimulus to the HPA axis. Chronic intrauterine hypoxemia can up-regulate the setpoint of the HPA axis and augments adrenal steroidogenic production, resulting in sustained elevation of circulating cortisol levels.
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Prickett TCR, McNeill BA, Oliver MH, Harding JE, Espiner EA. Effect of cortisol on C-type natriuretic peptide in ovine pregnancy: differential responses in fetal and placental tissues. Pediatr Res 2010; 68:462-5. [PMID: 20802376 DOI: 10.1203/pdr.0b013e3181f9039d] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We have used aminoterminal pro C-type natriuretic peptide (NTproCNP)--a stable marker of CNP secretion--to study the effect of cortisol on CNP secretion and fetal growth. In ovine pregnancy, maternal plasma NTproCNP (largely sourced from the placenta) increases at the end of the first trimester and then decreases abruptly preterm during the phase of fetal surge in cortisol secretion. Postulating that increases in cortisol, as occurs in the fetal or maternal circulation in late pregnancy, will reduce CNP secretion, we studied the fetal and maternal responses in NTproCNP to sustained low-dose infusions of cortisol (1.2 mg/d/kg for 11 d) delivered to the fetus from d 117 gestation. Fetal plasma NTproCNP was progressively reduced during fetal cortisol infusions, whereas fetal girth growth was unchanged. In contrast, maternal NTproCNP was unaffected by cortisol. We conclude that fetal but not placental tissue production of CNP is reduced by small increments in fetal cortisol. Failure to reduce maternal NTproCNP may relate to the continuing presence of the placental barrier to cortisol at this stage of pregnancy.
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Abstract
There is strong evidence that prolonged, moderate cerebral hypothermia initiated within a few hours after severe hypoxia-ischemia and continued until resolution of the acute phase of delayed cell death can reduce neuronal loss and improve behavioral recovery in term infants and adults after cardiac arrest. This review examines the evidence that mild to moderate hypothermia is protective after hypoxia-ischemia in models of preterm brain injury and evaluates the potential risks. Induced hypothermia likely has potential to significantly reduce disability. Cautious, systematic trials are essential before hypothermia can be used in these vulnerable infants.
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Affiliation(s)
- Alistair Jan Gunn
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand.
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